www.jcrpjournal.com Physical Activity During COVID-19 285
Impact of COVID-19 Pandemic on Physical Activity in
Patients With Implantable Cardioverter-Defibrillators
Biagio Sassone, MD; Simona Mandini, PhD; Giovanni Grazzi, MD; Gianni Mazzoni, MD;
Jonathan Myers, PhD; Giovanni Pasanisi, MD
Brief Report
Author Affiliations: Department of Morphology, Surgery and Experimental
Medicine, University of Ferrara, Ferrara, Italy (Dr Sassone); Department of Emergency, Division of Cardiology, AUSL Ferrara, Ferrara, Italy (Drs Sassone and Pasanisi); Centre for Exercise Science and Sport, University of Ferrara, Ferrara, Italy (Drs Mandini, Grazzi, and Mazzoni); Public Health Department, AUSL Ferrara, Ferrara, Italy (Drs Grazzi and Mazzoni); and Division of Cardiology, VA Palo Alto, Palo Alto, California, and Stanford University School of Medicine, Stanford, California (Dr Myers).
The authors declare no conflicts of interest.
Correspondence: Giovanni Pasanisi, MD, Division of Cardiology, Delta
Hospital, via Valle Oppio 2, 4023 Lagosanto, Ferrara, Italy (g.pasanisi@ausl.fe.it). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/HCR.0000000000000539
Purpose: The coronavirus disease-2019 (COVID-19) pandem-ic has been spreading rapidly worldwide since late January 2020. The strict lockdown strategy prompted by the Italian govern-ment, to hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) spreading, has reduced the possibility of per-forming either outdoor or gym physical activity (PA). This study investigated and quantified the reduction of PA in patients with automatic implantable cardioverter-defibrillators (ICDs) for pri-mary prevention of sudden death.
Methods: Daily PA of 24 patients was estimated by processing recorded data from ICD-embedded accelerometric sensors used by the rate-responsive pacing systems.
Results: During the forced 40-d in-home confinement, a mean 25% reduction of PA was observed as compared with the 40-d confinement-free period (1.2 ± 0.3 vs 1.6 ± 0.5 hr/d, respectively, P = .0001).
Conclusions: This objective quantification of the impact of the COVID-19 pandemic on PA determined by an ICD device showed an abrupt and statistically significant reduction of PA in primary prevention ICD patients, during the in-home confine-ment quarantine. To counteract the deleterious effects of phys-ical inactivity during the COVID-19 outbreak, patients should be encouraged to perform indoor exercise-based personalized rehabilitative programs.
Key Words: cardioverter-defibrillators • COVID-19 • physical activity
T
he coronavirus disease-2019 (COVID-19) pandemic has prompted many governments to promote strict in-door isolation strategies to hamper the virus spreading by limiting human-to-human transmission. Respect for such necessary, but draconian, recommendations has unavoid-ably reduced the possibility of performing either outdoor or gym physical activity (PA). Physical inactivity is a major risk factor for cardiovascular disease.1 A large study on 185 000US subjects reported a steep fall in PA (by 48%) measured by Fitbit trackers since a Federal emergency was declared through April 6.2 However, so far, the literature is sparse
regarding precise quantification of a PA decline in cardi-ac patients during the COVID-19 pandemic. The expected
growing prevalence of physical inactivity raises concerns about the maintenance of well-established favorable effects of PA on physical and mental health in such patients.3 The
dose-response interaction between the immune system and PA has been described by a J-shaped curve, demonstrating the importance of regular and moderate-intensity exercise to improve the immune system.4,5 Accordingly, there is
general agreement in support of keeping physically active during the quarantine, especially for older patients.6
An implantable cardioverter-defibrillator (ICD) is the recommended treatment for either primary or secondary prevention of sudden cardiac death in selected high-risk pa-tients. Light-to-moderate exercise training programs in ICD recipients have resulted in similar benefits as in other cardi-ac patients.7-10 They also provide potential protective effects
against arrhythmic risk through autonomic nervous system balance, metabolic changes, and increasing coronary vascu-lar density and flow. In such patients, an ICD represents a unique tool for continuous monitoring of PA via embedded accelerometric sensors used by the rate-responsive pacing systems.11
The aim of this study was to investigate and quantify changes in PA during the in-home confinement in patients implanted with ICDs.
METHODS
We analyzed data of 24 patients (72 ± 10 yr, 17 males) implanted with ICDs (Boston Scientific) for primary preven-tion of sudden death and with home-monitoring follow-up. Such ICDs enable a continuous monitoring and recording of PA via embedded accelerometric sensors used by the rate-responsive pacing systems. Recorded data were then processed by a specific algorithm and translated into esti-mates of time spent in movement, that has been used as sur-rogate of PA.11 Device-based recordings of patient PA levels
were quantified as hr/d and assessed across two timespans: 40 d before and 40 d after the national lockdown began, respectively (Figure).
RESULTS
During the forced 40-d in-home confinement, a 25% mean reduction of PA was observed as compared to the 40-d con-finement-free period (mean 1.6 ± 0.5 vs 1.2 ± 0.3 hr/d, respectively, P = .0001). Since left ventricular systolic dys-function is not uncommon in primary prevention ICD pa-tients, baseline exercise performance is expected to be low12
and this may account for the relatively shallow decline in PA of our patients. Thus, data were reanalyzed after ex-cluding very inactive patients (ie, PA <1 hr/d), but results did not change showing a significant decrease in PA after lockdown began (2.0 ± 0.6 vs 1.5 ± 0.4 hr/d, respectively,
P = .0001).
286 Journal of Cardiopulmonary Rehabilitation and Prevention 2020;40:285-286 www.jcrpjournal.com
DISCUSSION
This may be the first objective quantification of the impact of the COVID-19 pandemic on PA determined by an ICD device. An abrupt cessation of physical exercise has been associated with rapid loss of PA-related benefits. A mild reduction by even 25% of daily PA in poorly trained ICD patients may underlie a clinically significant worsening of frailty (eg, increasing fall risk) and loss of metabolic, car-diovascular, and musculoskeletal conditioning within just two weeks. To counteract the deleterious effects of physical inactivity during the COVID-19 outbreak, patients should be encouraged to perform indoor exercise-based personal-ized rehabilitative programs.13-15
REFERENCES
1. Kaminsky LA, Brubaker PH, Guazzi M, et al. Assessing Physi-cal Activity as a Core Component in Cardiac Rehabilitation: A Position statement of the American Association of Cardiovascu-lar and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev. 2016;36(4):217-229.
2. Evidation Health, Inc. COVID-19 pulse: delivering regular in-sights on the pandemic from a 150,000+ person connected cohort. https://evidation.com/news/covid-19-pulse-first-data-evidation/. Updated April 15, 2020.
3. Lippi G, Henry BM, Sanchis-Gomar F. Physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (COVID-19) [published online ahead of print April 9, 2020]. Eur J
Prev Cardiol. doi:10.1177/2047487320916823.
4. Kakanis MW, Peake J, Brenu EW, et al. The open window of sus-ceptibility to infection after acute exercise in healthy young male elite athletes. Exerc Immunol Rev. 2010;16:119-137.
5. Rahmati-Ahmadabad S, Hosseini F. Exercise against SARS-CoV-2 (COVID-19): does workout intensity matter? (A mini review of some indirect evidence related to obesity). Obes Med. 2020;19;100245. doi:10.1016/j.obmed.2020.100245.
6. Pavon DJ, Baeza AC, Lavie CJ. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: special focus in older people [published online ahead of print March 24, 2020]. Prog Cardiovasc Dis. doi:10.1016/j. pcad.2020.03.009.
7. Vanhees L, Kornaat M, Defoor J, et al. Effect of exercise training in patients with an implantable cardioverter defibrillator. Eur Heart
J. 2004;25(13):1120-1126.
8. Alswyan AH, Sauer Liberato AC, Dougherty CM. A systematic review of exercise training in patients with cardiac implantable de-vices. J Cardiopulm Rehabil Prev. 2018;38(2):70-84.
9. Dougherty CM, Burr RL, Kudenchuk PJ, Glenny RW. Aerobic ex-ercise effects on quality of life and psychological distress after an implantable cardioverter defibrillator. J Cardiopulm Rehabil Prev. 2020;40(2):94-101.
10. Steinhaus DA, Lubitz SA, Noseworthy PA, Kramer DB. Ex-ercise interventions in patients with implantable cardioverter- defibrillators and cardiac resynchronization therapy. J Cardiopulm
Rehabil Prev. 2019;39(5):308-317.
11. Puppala VK, Hofeld BC, Anger A, et al. Pacemaker detected active minutes are superior to pedometer-based step counts in measur-ing the response to physical activity counselmeasur-ing in sedentary older adults. BMC Geriatr. 2020;20(1):162.
12. Kramer DB, Tsai T, Natarajan P, et al. Frailty, physical activi-ty, and mobility in patients with cardiac implantable electrical devices. J Am Heart Assoc. 2017;6(2):e004659. doi:10.1161/ JAHA.116.004659.
13. Thomas RJ, Beatty AL, Beckie TM, et al. Home-based cardiac re-habilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J
Car-diopulm Rehabil Prev. 2019;39(4):208-225.
14. Berry R, Brawner CA, Kipa SG, Stevens C, Bloom C, Keteyian SJ. Telemedicine home-based cardiac rehabilitation: a case series.
J Cardiopulm Rehabil Prev. 2020;40(4):245-248.
15. Yeo TJ, Wang YL, Low TT. Have a heart during the COVID-19 crisis: making the case for cardiac rehabilitation in the face of an ongoing pandemic. Eur J Prev Cardiol. 2020;27(9):903-905. Figure. A patient’s daily physical activity over time. The fragmented gray curve indicates daily activity in hours, whereas the smooth curve represents mean values by 3-d groups. The arrow indicates the beginning of the in-home confinement quarantine over the whole national Italian territory (March 12, 2020); from this date onward, the curve falls abruptly down and appears flat with little daily variation of physical activity.
